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CASE PRESENTATION Dr. Mario Melgar Guatemala THE PATIENT • MDM • Age: 11 years old • Origin: Guatemala city History of Disease • Dysphagia 3 weeks, treated with antiinflammatories • CBC: Hyper leukocytosis • Transfer to UNOP • July 8, 2008 – Diagnosis: AML M4 – 245,000 WBC – CSF negative, Thorax negative – Fever, oral lesions • Ceftazidime, Fluconazole • July 10, 2008 – Hypo tension – ICU – Vancomycin • July 12 – Start on chemotherapy protocol (ADE) – G-CSF • July 16 – Acyclovir • July 21 – Withdraw Vancomycin – Diarrhea – Neutropenia • July 22 – Septic shock – Meropenem – Amikacyn – Amphotericyn B • July 24 – Vancomycin re started • July 26 – Improvement in clinical condition – Out of ICU • July 29 – Amphoterecyn B withdraw • July 30 – TNC 310 • August 1 – TNC 1780 – Withdraw atbs – 4 hours later fever – Cultures – Cardiomegaly in X-rays 7/ 14 /2 7/ 0 08 16 /2 7/ 0 08 18 /2 7/ 0 0 20 8 /2 7/ 0 08 22 /2 7/ 0 08 24 /2 7/ 0 0 26 8 /2 7/ 0 08 28 /2 7/ 0 08 30 /2 0 8/ 08 1/ 20 8/ 0 8 3/ 20 8/ 0 8 5/ 20 8/ 0 8 7/ 20 8/ 0 8 9/ 2 8/ 00 8 11 /2 00 8 8/11/2008 8/9/2008 8/7/2008 8/5/2008 8/3/2008 8/1/2008 7/30/2008 7/28/2008 7/26/2008 7/24/2008 7/22/2008 7/20/2008 7/18/2008 7/16/2008 7/14/2008 7/12/2008 7/10/2008 7/8/2008 CRP 250 200 150 CRP 100 50 0 80000 70000 60000 50000 40000 30000 20000 10000 0 WBC TNC • Look back pericardial effusion – – – – July 11 small pericardial effusion 8mm July 16 pericardial effusion 10mm New echocardiogram August 4 pericardial effusion 15mm, septated • August 5 – Pericardial drainage and biopsy • 100 cc serohematic • 117 WBC (76% Lymph, 24% PMN) • Stains and cultures negative • August 7 – Chest CT • Basal consolidation in both lungs • Needle biopsy – not enough material Pericardial biopsy • In some miocytes and histiocytes presence of eosinophylic nuclear inclusions sugesting CMV infection PERICARDIAL EFFUSION • • • • CMV infection? Other virus? Neoplasic infiltration? Drug toxicity? CMV pericarditis • Frasca 1980 – Review of viral serositis and pericarditis – Of 47, 5 influenza viruses, 1 parainfluenza, 1 coxsackie, 1 RSV, 3 mumps virus,, 1 adenovirus, 5 CMV • Saatsi 1993 – Case report of CMV pericarditis – Renal transplant recipient • Campbell, 1995 – 57 pericardial effussions in adults – 3 culture proven, 1 serological CMV – 1 infant with congenital hearth disease Boll Ist Sieroter Milan. 1980 May 31;59(2):112-20 Int Urol Nephrol. 1993;25(6):617-9. Links Am J Med Sci. 1995 Apr;309(4):229-34 Other viruses • Daibata 1997 – 47 yo man, AML – Pericarditis due to HHV 6 • Aoyama 2004 – 31 yo woman, AML – Pericarditis – EBV reactivation Leuk Lymphoma. 2004 Feb;45(2):393-5 Leukemia. 1997 Jun;11(6):882-5. Infiltration • Wong, 2004 – 47 years, – Constrictive pericarditis – Etiology: tumor infiltration • Da Costa, 1999 – 2 year old AML – Cardiac tamponade at presentation with hyper leukocytosis Medical and Pediatric Oncology 32:120–123 (1999) Circulation. 2004;109:e146-e149 Drugs • Galer,2003 – Patient with acute mielomonoblastic leukemia – Pericarditis due to Cytarabine • Larrea, 1997 – Case report – ATRA syndrome – Cardiac tamponade, treatment with steroids and pericardiocentesis Haematologica 1997; 82:463-464 Onkologie. 2003 Aug;26(4):348-50 In our patient • Probably tumor infiltration • August 7 – Started chemo – Fever stopped – Good clinical evolution – New CT pending for assessment of lung consolidations Comments…